Considerations for the Use of Alloplastic Temporomandibular Joint Replacement in the Growing Patient

Can growing patients with end-stage TMJ pathology be successfully treated with alloplastic temporomandibular joint reconstruction? - A systematic review

INTRODUCTION

The use of alloplastic total temporomandibular joint reconstruction (TMJR) in growing patients is controversial, mainly due to immature elements of the craniomaxillofacial skeleton. The aim of this systematic review was to evaluate the use of alloplastic TMJR in growing patients, focusing on the patient's clinical presentation, surgical and medical history and efficacy of alloplastic TMJR implantation.

MATERIALS AND METHODS

The literature search strategy was based on the Population, Intervention, Comparator, Outcomes and Study type (PICOS) framework. We searched Pubmed, Google Scholar, Dimension, Web of Science, X-mol, Semantic Scholar and Embase to January 2023, without any restriction on the type of publication reporting alloplastic TMJR in growing patients (age ≤ 18 years for boys and age ≤ 15 years for girls).

RESULTS

A total of 15 studies (case reports: 09, case series: 02, cohort studies: 04) met the inclusion criteria, documenting 73 patients of growing age from 07 countries. Thirty-eight (~ 52%) cases were female. The mean ± SD (range) age and follow-up of patients in all studies was 13.1 ± 3.2 (0-17) years and 34.3 ± 21.5 (7-96) months, respectively. A total of 22 (30%) patients were implanted with bilateral alloplastic TMJR. Over half of the studies (n = 10) were published in the last 3 years. All patients underwent multiple surgeries prior to implantation of alloplastic TMJR. In extreme cases, patients underwent a total of 17 surgeries. Different types of studies reporting inconsistent variables restricted our ability to perform quality assessment measures for evidence building.

CONCLUSIONS

Clinical experience with alloplastic TMJR in growing patients is limited to cases showing poor prognosis with other types of reconstruction. Nevertheless, studies show promising results for the use of alloplastic TMJR in growing patients, highlighting the need for well-controlled prospective studies with long-term follow-up.

Alloplastic TMJ replacement in the skeletally immature patient - A systematic review

This study assessed the current evidence for the use of TMJR reconstruction in skeletally immature patients. A systematic review was conducted according to PRISMA guidelines. An electronic search in PubMed and Embase was performed. Meta-analysis randomized controlled trials (RCTs), cohort studies, observational studies, case series, and case reports were eligible for inclusion. Case reports were also included due to the limited number of publications identified with the predefined terms. Exclusion criteria were: (1) studies written in a language other than English; (2) full-text unavailability (i.e., posters and conference abstracts). The selected studies were assessed for risk of bias. A meta-analysis was not performed as it necessitates a substantial between-study design homogeneity; hence, a descriptive synthesis of data was performed. There were 9 TMJR device reconstruction studies involving 14 subjects 13 years of age or younger. Follow-up ranged from 7 months to 120 months. All papers reported significant decrease in pain and improvement of diet. All prostheses were functional. No material failures of the prosthesis components were observed. The mandible continued to show limited growth following TMJR and most of the cases required no secondary or revision surgery even when the patient reached skeletal maturity. This systematic review had some limitations. The studies included had a low level of evidence and a high risk of bias. Most of the studies had a small patient sample, and no study had a control group. The literature reviewed supports the use of TMJR devices in the restoration of mandibular function and form in skeletally immature patients.

Total temporomandibular joint reconstruction prosthesis in hemifacial microsomia: A systematic review

Hypoplastic asymmetry due to hemifacial microsomia (HFM) often represents the most difficult reconstruction in the craniomaxillofacial clinic. Although autogenous grafts are generally used for temporomandibular joint reconstruction (TMJR), the use of TMJR prostheses is not well established. The aim of this review was to identify, collect and analyse the use of extended TMJR (eTMJR) prostheses in patients with HFM, describing clinical features, surgical procedures and postoperative complications. Online searches of all major databases were performed according to PRISMA guidelines. All studies with HFM patients treated with the eTMJR prostheses were included. Descriptive statistics were used for data analysis. A total of 19 studies, including 08 case studies, 06 case series and 05 retrospective cohort studies, met the inclusion criteria, where a total of 42 HFM patients were reported from 18 countries, mostly from the United States (05; 26%). Fifteen of the 42 cases (~36%) were male. The mean ± SD (range) age of patients in all studies was 19.79 ± 5.81 (9-36) years. The mean ± SD (range) of patient follow-up was 41.30 ± 35.50 (6-136) months. A total of 5 (10.6%) patients were implanted with bilateral eTMJR prostheses. The Pruzansky classification was used in 18 (~89.5%) studies, OMENS classification in 01 (~5%) study, whereas no classification was reported in one study. Only 01 (7.1%) study had documented the eTMJR classification for the prosthesis used. In growing patients with or without a history of failed autogenous tissues, TMJR prostheses may provide a viable alternative. Randomized studies with large cohorts are warranted to validate these preliminary results.

Dentinogenic Ghost Cell Tumour in Childhood Involving the Temporomandibular Joint: Considerations and Therapy

Background

Although the uncommon dentinogenic ghost cell tumour (DGCT) is a benign entity, it possesses the ability to cause widespread destruction of the jaws and to recur after bone-preserving therapy. Hence, clear margins should be achieved upon surgery, and reconstruction techniques must often be used to restore osseous defects. However, this can be challenging in cases with involvement of the temporomandibular joint (TMJ), and especially in children.

Case report

We present a case of a DGCT in a 12-year-old boy with wide infiltration of the mandible and the TMJ. A two-staged reconstructive approach was performed. Upon primary surgery, tumour-free margins were obtained and mandibular anatomy was restored using an iliac crest graft and an alloplastic condyle implant for temporary TMJ reconstruction. In a second step 5 months later, having received a customized TMJ prosthesis consisting of a fossa and a condyle component, the TMJ was completely replaced for definitive reconstruction.

Conclusion

A customized TMJ prosthesis could be a solution for reconstruction of the TMJ in children. However, the further course with respect to growth disturbances must be evaluated upon short-term follow-ups and might require additional corrective interventions.

Concomitant Temporomandibular Joint Replacement and Orthognathic Surgery

The treatment of patients with severe temporomandibular joint (TMJ) disorders and associated skeletal discrepancies presents a complex challenge for oral and maxillofacial surgeons. It is widely recognized that TMDs can impact the stability and outcomes of surgical treatments for dentofacial deformities. Consequently, addressing TMDs prior to or in conjunction with orthodontic or surgical interventions may be necessary to achieve optimal and long-lasting results. Alloplastic temporomandibular joint replacement (TMJR) and orthognathic surgery have emerged as the standard approach due to their predictability, long-term stability and excellent outcomes when addressing end-stage TMJ disease in conjunction with DFDs as it provides a comprehensive solution to address both functional and aesthetic aspects of these patients' conditions. Understanding the appropriate utilization of TMJR in conjunction with orthognathic surgery can lead to improved treatment planning and successful outcomes for patients with complex TMJ disorders and associated dentofacial deformities. This review aims to discuss the indications, preoperative evaluation, staging, sequencing, and surgical considerations involved in utilizing alloplastic TMJ replacement in the presence of dentofacial deformities.

Management of the secondary growth defect

Temporomandibular reconstruction has clear aims including the restoration of mandibular form and function, to decrease patient disability and to prevent disease progression. In addition paediatric patients have growth and re-modelling considerations and the need to minimise any secondary growth defect. The involvement of a multidisciplinary team is deemed essential for both the child and parents. In some patients crisis intervention may be required and early reconstruction might be necessary dependant on the severity of impairment. The aetiology of end stage TMJ disease, unilateral/bilateral disease and the degree of patient compromise will guide timing and choice of treatment. Reducing repeated surgery and facilitating patient compliance may potentiate mandibular growth.

Congenital Mandibular Hypoplasia: Patient-Specific Total Joint Replacement as a Line Extension in the Treatment of Complex Craniofacial Anomalies

Introduction

Congenital mandibular hypoplasia (CMH) remains challenging because of the underlying combined hard and soft tissue deficiency. Treatment options include craniofacial distraction, orthognathic surgery, and autologous grafts, although the latter produces inadequate results after distraction and autologous grafting. Unsatisfactory long-term stability may cause relapse, necessitating reoperation.

Material and Methods

We investigated the feasibility of using alloplastic total joint replacement (TJR) in growing and young adult CMH patients. The primary outcome was long-term reconstruction stability, without implant failure. Secondary outcomes were TMJ function and pain, and jaw movements achieved during surgery.

Results

Three patients (age: 9–22 years) were treated by the same surgeon at one institution during 2018–2021. Anamnesis and clinical parameters were obtained from patient records. Preoperative 3D-scans were superimposed with postoperative 3D-scans and preoperative plans, including TJR-implant STL files, to measure jaw movement. All patients underwent prior reconstructive surgery. Mandibular movement of 16.4–20.1 mm in the sagittal direction was achieved. Post-TJR follow-up ranged from 24 to 42 months. No long-term complications occurred. At the latest follow-up, the maximal interincisal opening was between 21 and 40 mm, and all implants were functioning, without failure.

Conclusion

In selected CMH cases, alloplastic TJR can deliver satisfactory medium-term results with predictable and stable outcomes, even in growing patients.

Controversial Aspects of Diagnostics and Therapy of Arthritis of the Temporomandibular Joint in Rheumatoid and Juvenile Idiopathic Arthritis-An Analysis of Evidence- and Consensus-Based Recommendations Based on an Interdisciplinary Guideline Project

Introduction: Due to potentially severe sequelae (impaired growth, condylar resorption, and ankylosis) early diagnosis of chronic rheumatic arthritis of the temporomandibular joint (TMJ) and timely onset of therapy are essential. Aim: Owing to very limited evidence the aim of the study was to identify and discuss controversial topics in the guideline development to promote further focused research. Methods: Through a systematic literature search, 394 out of 3771 publications were included in a German interdisciplinary guideline draft. Two workgroups (1: oral and maxillofacial surgery, 2: interdisciplinary) voted on 77 recommendations/statements, in 2 independent anonymized and blinded consensus phases (Delphi process). Results: The voting results were relatively homogenous, except for a greater proportion of abstentions amongst the interdisciplinary group (p < 0.001). Eighty-four percent of recommendations/statements were approved in the first round, 89% with strong consensus. Fourteen recommendations/statements (18.2%) required a prolonged consensus phase and further discussion. Discussion: Contrast-enhanced MRI was confirmed as the method of choice for the diagnosis of TMJ arthritis. Intraarticular corticosteroid injection is to be limited to therapy-refractory cases and single injection only. In adults, alloplastic joint replacement is preferable to autologous replacement. In children/adolescents, autologous reconstruction may be performed lacking viable alternatives. Alloplastic options are currently still considered experimental.

Preoperative Arterial Coil Embolization for Temporomandibular Joint (TMJ) Surgery in Children with TMJ Ankylosis

ABSTRACT

Temporomandibular joint (TMJ) ankylosis in children can alter facial development and affect oral hygiene and function. Surgical release of the ankylosis is the mainstay of treatment. The authors hypothesize that preoperative arterial coil embolization is safe and effective in preventing major blood loss during TMJ surgery (loss prompting blood transfusion or hemodynamic instability requiring vasoactive medication administration) in children with TMJ ankylosis. Patients < 16 years who were diagnosed with TMJ ankylosis (<15 maximal interincisal opening) and had embolization before surgery in the last 5 years were included. Out of 9 initial search results, 3 patients were excluded (age > 16). Information gathered were patient demographics, diagnostic imaging, procedural details, complications, and clinical outcomes. Six patients, mean age 11.14 years (range 7-15 years) year and a mean weight of 40.8 ± 19 kg were included. Underlying etiologies for TMJ ankylosis: Pierre Robin Syndrome (n = 2), juvenile rheumatoid arthritis (n = 1), Goldenhar's syndrome (n = 1), trauma (n = 1), and micrognathia (n = 1). Neck computed tomography angiogram before embolization demonstrated an intimate approximation between the internal maxillary artery (IMAX) and/or external carotid artery and ankylotic mass in all patients. Eight successful embolizations were performed without procedural complication. In 1 patient with angiographic evidence of surgical internal maxillary artery ligation, embolization was performed via collaterals. Surgery was performed within 48 hours of embolization. Airway access during surgery was via nasal intubation (n = 4), oral intubation (n = 3). The estimated blood loss (EBL) during surgery was 78.33 ± 47.08 ml. Three patients had subsequent TMJ surgery with a mean estimated blood loss of 73.33 ± 46.18 ml. After a mean follow-up of 17 ± 15 months, patients showed a 13.8 mm mean increment of maximal interincisal opening with 95% CI (5.74-21.9), P < 0.007.

Clinical Practice Guideline: The Diagnosis and Treatment of Rheumatoid Arthritis and Juvenile Idiopathic Arthritis of the Temporomandibular Joint

BACKGROUND

Involvement of the temporomandibular joint can be shown in 40-90% of patients with rheumatoid arthritis and juvenile idiopathic arthritis (JIA), although it is often asymptomatic. Restricted jaw mobility and jaw pain can be found in approximately 20% of patients with JIA (prevalence: 70 per 100 000 persons). Early diagnosis and treatment of the underlying disease are essential for a good outcome, but uniform, consensus-based management is still lacking.

METHODS

The clinical practice guideline is based on the findings of a systematic literature review in multiple databases and a Delphi procedure to obtain consensus on the recommendations.

RESULTS

Most of the identified studies were retrospective. Patients with JIA should undergo clinical screening with a structured examination protocol once per year in childhood and adolescence, and thereafter as well if the temporomandibular joint is involved. The diagnosis of chronic rheumatoid arthritis of the temporomandibular joint is established with contrastenhanced magnetic resonance imaging. Conservative treatment (antirheumatic basal therapy, local measures) is unsuccessful in less than 10% of patients. In such cases, arthroscopy and arthrocentesis can be used for temporary symptom relief and functional improvement. Intraarticular corticosteroid injections should be given only once, and only in otherwise intractable cases. In severe cases where all other options have been exhausted (<1%), open surgical treatment can be considered, including alloplastic joint replacement.

CONCLUSION

Oligosymptomatic and asymptomatic cases are common even with radiologic evidence of marked joint damage. The possibility of rheumatic involvement of the temporomandibular joint must be kept in mind so that serious complications can be avoided. Regular clinical evaluation of the temporomandibular joint is recommended, particularly for patients with juvenile idiopathic arthritis.

Protocol for Multi-Stage Treatment of Temporomandibular Joint Ankylosis in Children and Adolescents

Treatment of temporomandibular ankylosis is challenging and frequently leads to re-ankylosis, relapse, dangerous complications and, in turn, the need for multiple operations. In this article, we present a protocol for the treatment of ankylosis of the temporomandibular joints that assumes earlier intervention with the assistance of 3D virtual surgical planning (3DVSP) and custom biomaterials for better and safer surgical outcomes. Thirty-three patients were treated due to either uni- or bilateral temporomandibular ankylosis. Twenty individuals received temporomandibular prosthesis, whereas seventeen required simultaneous 3D virtual surgical/planned orthognathic surgery as the final correction of the malocclusion. All patients exhibited statistically significant improvements in mouth opening (from 1.21 ± 0.74 cm to 3.77 ± 0.46 cm) and increased physiological functioning of the mandible. Gap arthroplasty and aggressive rehabilitation prior to temporomandibular prosthesis (TMJP) placement were preferred over costochondral autografts. The use of 3DVSP and custom biomaterials enables more precise, efficient and safe procedures to be performed in the paediatric and adolescent population requiring treatment for temporomandibular ankylosis.

Total Alloplastic Temporomandibular Joint Replacement

Purpose

End-stage temporomandibular joint (TMJ) disease are not uncommon and affects quality of life. Multiple surgical procedures have been mentioned in literature for management of TMJ disease which ranges from conservative management to aggressive resection of involved joint and replacement with alloplastic total joint prosthesis. The purpose of the present paper was to provide an overview of the role of alloplastic total joint prosthesis in TMJ replacement.

Methods and results

Alloplastic total joint prosthesis is nowadays considered as a standard of care in the adult patients who require TMJ replacement. The requirement of alloplastic total prosthesis has increased in present era with the improvement in design and material of implants, surgical skills and reported victorious outcome along with improved quality of life after its use. It provides restoration of form and functions, improvement in quality of life, reduction in pain and maintenance of ramal height. Additionally, in TMJ ankylosis it reduces chances of re-ankylosis and allows facial asymmetry correction. Currently, enough evidence is however not available for replacement in skeletally immature patient.

Conclusion

The authors conclude that the total joint replacement is a standard procedure for end-stage TMJ disease. Every maxillofacial surgeon should be well-acquainted with TMJ replacement.

Alloplastic total joint replacement in management of temporomandibular joint ankylosis

Both autogenous and alloplastic material have been used in management of temporomandibular joint (TMJ) ankylosis. Second surgical site, donor site morbidity, possibility of over/undergrowth, graft fracture or resorption and increased surgical time are the disadvantages of autogenous graft. Alloplastic total joint replacement (TJR) has become a promising technique in management of adult temporomandibular joint ankylosis (TMJA). This paper intends to present the role of alloplastic TJR in management of TMJA. There is significant current evidence of the role of alloplastic TJR in the management of TMJA. Results in TMJA are excellent with sustained improvement in pain free mouth opening, correction of facial asymmetry, reduction in recurrence and improved quality of life. TMJ TJR is becoming the gold standard of care in the management of TMJA, although costs can sometime preclude access to this mode of therapy.

A conceptual framework for treating jaw deformities in patients with abnormal condyles: preservation versus replacement of the glenoid fossa-disc-condyle-ramus

This article outlines a conceptual approach to the reconstruction of jaw deformities associated with abnormalities in the mandibular condyle. The authors describe a hierarchy of reconstruction, emphasizing use of the least invasive and progressing to the most complex and invasive techniques, depending on the nature and severity of the underlying deformity, prior operations, patient age, and stage of growth. Consider joint preservation orthognathic surgical correction, followed by biological techniques for replacement of the condyle, and avoid replacing a functional temporomandibular joint based only on radiographic remodeling and concerns about potential future flare-ups of disease based on anecdotal data.

Patient specific total temporomandibular joint reconstruction: A review of biomaterial, designs, fabrication and outcomes

Purpose

The aim of this article was to systematically review the available literature on patient specific total temporomandibular joint total joint replacement (PS-TMJR) implants for their biomaterial, designs, fabrication techniques and their outcomes.

Methods

A literature review was conducted using PubMed, and science direct databases using the key words three-dimensional printing, 3D printing, CAD CAM, computer aided designing, computer aided manufacturing, additive technology, custom made implants, patient specific implants in combination with Temporomandibular joint, TMJ surgery.

Results

The search revealed 2760 articles, of which 374 were in English and discussed TMJ reconstruction. Further filtering shortlisted 74 articles that discussed PS-TMJR. Duplicates were removed and additional added from article references. 39 articles describing biomaterial, designing and fabrication of PS-TMJR implants and their outcomes were selected for analysis.

Conclusions

Although PS-TMJR implants allow a better anatomical fit, improved fixation, and safeguard various structures such as the inferior alveolar nerve, they vary in designs, material and fabrication techniques. However, PS-TMJR printed with SLM and EBM technologies have yet to be compared with the conventional ones in terms of mechanical strength, and clinical outcome. With emerging bioprinting technologies, even newer biomaterials should be considered for 3D printing of PS-TMJR devices designed to achieve harmony in function between the joint device, bone and masticatory muscles.

Management of inflammatory temporomandibular joint collapse in children

Juvenile idiopathic arthritis is the most common pediatric rheumatologic condition.( Abramowicz et al., 2016 Jul) 2 The etiology and pathogenesis have not been fully elucidated; a combination of environmental and certain immunogenic factors is suspected. This review will provide current knowledge and concepts of diagnosis and management of children with JIA and TMJ arthritis.

Custom Alloplastic Temporomandibular Joint Reconstruction: Expanding Reconstructive Horizons

Custom alloplastic temporomandibular joint (TMJ) reconstruction has been well established for the management of end-stage TMJ disease. However, its use in congenital TMJ deformities is limited. Here, the authors present initial outcomes of skeletally mature patients who underwent custom alloplastic TMJ reconstruction and simultaneous orthognathic surgery.A retrospective case series of patients who underwent custom alloplastic TMJ reconstruction concurrent with orthognathic surgery between 2014 and 2019 was completed. Functional, aesthetic and orthodontic outcomes as well as complications were recorded.Seven TMJs in 5 skeletally mature patients (4 female, 1 male, ages 16-30) (2 bilateral, 3 unilateral) were replaced. All but 1 patient had previous attempts at reconstructive surgery with poor results. All cases were prepared using virtual surgical planning and underwent concomitant maxillomandibular orthognathic surgery. All patients demonstrated improved post-operative occlusions. Four of 5 patients achieved >30 millimeters of post-operative MIO. Complications included ear canal perforation and facial nerve dysfunction.There were no infections or other implant-related complications. Mean follow up was 2 years and 15 days. Alloplastic TMJ reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects is an alternative to existing management options. Further long-term prospective outcomes studies are ongoing.

Prosthetic temporomandibular joint reconstruction in a cohort of adolescent females with juvenile idiopathic arthritis

BACKGROUND

Temporomandibular joint (TMJ) arthritis and involvement is commonly seen in Juvenile Idiopathic Arthritis (JIA). Therapy includes conservative measures, but also includes intraarticular corticosteroid injections (IASI) and systemic immunosuppressive therapy. Despite aggressive medical therapy, some patients develop arthritic changes and frank TMJ ankylosis that can result in persistent pain and limitation in range of motion (ROM). A surgical option is prosthetic TMJ replacement with concurrent correction of dentofacial deformities, which can be performed simultaneously. The objective of this study was to evaluate the outcomes of prosthetic TMJ replacement in a cohort of adolescent females with JIA and severe TMJ involvement.

METHODS

This is a retrospective case series that took place at one tertiary care center. Patients with a diagnosis of JIA who also underwent alloplastic TMJ replacement were identified through electronic medical record system (EMR) and reviewed. Chart review included analysis of all documents in the EMR, including demographic data, JIA history, surgical complications, ROM of TMJ measured by maximal incisal opening in millimeters (mm) and TMJ pain scores (4-point Likert scale: none, mild, moderate, severe) obtained pre- and postoperatively.

RESULTS

Five female patients, ages 15-17 year when TMJ replacement was performed, had nine total joints replaced with a post-operative follow-up period of 12-30 months. All patients had polyarticular, seronegative JIA and were treated with IASI and multiple immunosuppressive therapies without resolution of TMJ symptoms. One patient had bilateral TMJ ankylosis. Three of the five patients demonstrated significant dentofacial deformities, and all underwent simultaneous or staged orthognathic surgery. All patients had improvement in TMJ pain with most (80%) reporting no pain, and all had similar or improved ROM of their TMJ postoperatively. There was one delayed postoperative infection with Cutibacterium Acnes that presented 15 months after surgery and required removal and reimplantation of prosthesis.

CONCLUSION

The sequelae of TMJ arthritis and involvement from JIA in the adolescent population can be difficult to treat. Current medical therapy can be successful, however, in select cases that develop chronic changes in the TMJ despite extensive medical therapy, early results show that prosthetic joint replacement maybe a reasonable surgical option. With prosthetic joint replacement pain levels were reduced and range of motion was maintained or improved for all patients.

Interdisciplinary Management of Dentofacial Deformity in Juvenile Idiopathic Arthritis

Temporomandibular joint (TMJ) arthritis impacts mandibular growth and development. This can result in skeletal deformity, such as facial asymmetry and/or malocclusion asymmetry. This article reviews the unique properties of TMJ and dentofacial growth and development in the setting of juvenile idiopathic arthritis (JIA). Specific orthopedic/orthodontic and surgical management of children with JIA and TMJ arthritis is discussed. The importance of interdisciplinary collaboration is highlighted.

Temporomandibular Joint Reconstruction in the Growing Child

Indications and considerations for reconstruction of the temporomandibular joint (TMJ) differ between growing and skeletally mature patients. Osteoarthritis, which is the most common cause of TMJ destruction in adults, is comparatively rare in children. The most common indications in young patients are congenital deformities, pathology, ankylosis and progressive resorptive processes. Options for reconstruction include distraction osteogenesis, autologous reconstruction (ie, costochondral graft, free fibula flap), and total alloplastic joint replacement. The choice of the ideal reconstruction is based on multiple factors, which include extent and laterality of the deformity, patient age, jaw growth pattern, and potential for progressive destruction.

Management of Temporomandibular Joint Ankylosis With Dentofacial Deformities in Children

This retrospective study described the authors' experience in the treatment of temporomandibular joint (TMJ) ankylosis with dentofacial deformities in 18 pediatric patients during a 4-year period. These patients underwent different types of arthroplasty with condylar reconstruction, simultaneously with treatment of dentofacial deformities. Re-ankylosis was confirmed if maximal incisal opening (MIO) was <20 mm. Clinical outcomes were evaluated in terms of oral function, radiography, and medical photography. Patients were followed up for a mean time of 24.8 months. No infections, re-ankylosis, or permanent facial nerve damage were found during the hospitalization or follow-up period. All patients achieved significant improvements in MIO and oral function. The dentofacial deformities in most patients were improved to varying degrees. The results provided more useful information for the management of the pediatric patients with TMJ ankylosis and secondary dentofacial deformities. Early treatment and close follow-up play an important role in the management of these patients.

Costochondral Graft Versus Total Alloplastic Joint for Temporomandibular Joint Reconstruction

Presently, there are 2 options for the replacement of the temporomandibular joint for end-stage pathology: autogenous bone grafting or alloplastic joint replacement. This article presents evidence-based advantages and disadvantages for each of these management options to assist both surgeons and their patients in making that choice.

Alloplastic reconstruction of the temporomandibular joint

Temporomandibular joint reconstruction (TMJR) is often necessary for patients with severe and/or refractory TMJ disease who have failed conservative treatment. TMJR aids to improve masticatory function and is associated with improved quality of life outcomes. Currently, alloplastic reconstruction is considered as the treatment of choice in most severe TMJ disorders due to its many advantages inclusive but not limited to early mobilization, stable longterm results, and significant improvement in jaw function. Broadly speaking, two types of TMJR prostheses are available for reconstruction: 1) stock, and, 2) custommade prostheses. The purpose of this article is to provide the reader with a brief overview of the basic principles and fundamentals of TMJR while referencing pertinent existing literature.

Goldenhar syndrome: current perspectives

BACKGROUND

Progress in medical branches that has taken place since the first child with Goldenhare syndrome (GS) had been described in 1952 by Maurice Goldenhar, facilitated better understanding of this congenital defect. It also gave new perspectives and the opportunity to achieve satisfactory treatment results, mainly due to development of surgical techniques.

DATA SOURCES

Based on the literature and own experience, we discussed the phenotype of presentation of GS, ethiopathogenesis, genetic counselling and treatment with particular emphasis on surgery correction of hemifacial microsomia.

RESULTS

The spectrum of GS abnormalities ranges from mild to severe ones and include patients with barely noticeable facial asymmetry to very pronounced facial defect with more or less severe abnormalities of internal organs and/or skeleton. It is characterized most commonly by impaired development of eyes, ears, lips, tongue, palate, mandible, maxilla, zygomatic and orbital structures and deformations of the teeth structures. Ethiopathogenesis is multifactorial and dependent on genetic and environmental factors but there are still many unknowns about the syndrome which should be revealed.

CONCLUSIONS

Patients with GS due to a large variety of abnormalities and different severity of symptoms pose a challenge for clinicians. All of this necessitate an individual approach to each single patient and involvement a team of specialists in treatment planning. It is a complex, long-lasting, multidisciplinary process and should be divided into stages, according to patient's age, as well as the extent and severity of observed abnormalities. Neonatologists and pediatricians are involved in care of these patients from the onset.

Juvenile arthritis: current concepts in terminology, etiopathogenesis, diagnosis, and management

The latest change in terminology from juvenile rheumatoid arthritis (JRA) to juvenile idiopathic arthritis (JIA), established by the International League of Associations for Rheumatology (ILAR), has resulted in some confusion for OMFS and other treating clinicians. JIA comprises a group of systemic inflammatory diseases that result in the destruction of hard and soft tissues in a single or multiple joints. In a significant number of patients, one or both temporomandibular joints (TMJ) are also involved. TMJ disease may be accompanied by pain, swelling, and limitation of motion, as well as mandibular retrognathism, open bite, and asymmetry. The purpose of this article is to provide a review, for the oral and maxillofacial surgeon, of the terminology, etiopathogenesis, diagnosis, and management of children with JIA.

The fate of autogenous free fat grafts in the human temporomandibular joint using magnetic resonance imaging

OBJECTIVE

Autologous fat grafts in the temporomandibular joint (TMJ) has achieved positive clinical effects in preventing adhesion after surgery. However it still remains indeterminate about the survival rate of grafted fat. The purpose of this study was to evaluate the long-term survival rate of free fat grafts in the TMJ using magnetic resonance imaging (MRI).

MATERIALS AND METHODS

89 patients (117 joints) with free fat grafts placed into TMJs following modified TMJ disc anchor were included in our study. They were divided into the following groups according to the time lapse between TMJ surgery and the latest MRI investigation: 1-3 months, 4-6 months, 7-12 months, 13-24 months, and >24 months. The signal intensity changes and volume retention were evaluated by MRI.

RESULTS

The volume retention rate of grafted free fat showed that the size was hovering right around 50% although it reduced very slowly with a long-term follow-up. Nearly half joints showed lower signal intensity of the grafted fat on MRI within 6 months and it recovered to normal compared with that of the day after surgery 6 months later.

CONCLUSIONS

Free fat grafted into TMJ cavity could be alive for a long time with the survival rate about 48.44%. However the survival mechanism has still been unknown, which need us to explore and study in the future.

Ramus Condyle Unit Reconstruction Using Vertical Ramus Osteotomy in Temporomandibular Joint Ankylosis

INTRODUCTION

Treatment of bony Temporomandibular Joint (TMJ) Ankylosis includes release of the ankylosis and creation of a gap with or without insertion of interposing material and complete reconstruction of the joint using e.g. costochondral, autogenous coronoid/ankylosed mass, sternoclavicular, clavicular bone grafts etc. As these are non-pedicled grafts, there is eventual resorption with subsequent decrease in height of the ramus, facial asymmetry, deviated mouth opening and reankylosis. The authors have applied the method of vertical ramus osteotomy (VRO) on the posterior border of the mandibular ramus for reconstruction of the ramus condyle unit (RCU) as a pedicled graft along with Myofascial Temporalis Interposition for the correction of TMJ Ankylosis.

MATERIALS AND METHODS

Ten patients of TMJ Ankylosis were included in this study. All ten patients were treated using VRO for the RCU reconstruction with posterior border of mandibular ramus after Gap Arthroplasty. Temporalis myofascial flap was used as an interpositional material in all patients. Patients were followed from 20 to 30 months (mean 24 months).

RESULTS

As a result of successful procedure the post-operative maximal mouth opening of 32-45 mm (mean 37 mm) was achieved. No patient experienced pain and infection at surgical site. None of the patients had graft rejection and reankylosis at follow-up.

CONCLUSION

The results showed that VRO on the posterior border of the mandibular ramus seems to be an alternative and promising method for RCU reconstruction in patients with TMJ Ankylosis.

Management of temporomandibular joint ankylosis

Temporomandibular joint (TMJ) ankylosis is a pathologic condition where the mandible is fused to the fossa by bony or fibrotic tissues. This interferes with mastication, speech, oral hygiene, and normal life activities, and can be potentially life threatening when struggling to acquire an airway in an emergency. Trauma is the most common cause of TMJ ankylosis, followed by infection. Diagnosis of TMJ ankylosis is usually made by clinical examination and imaging studies. The management goal in TMJ ankylosis is to increase the patient's mandibular function, correct associated facial deformity, decrease pain, and prevent reankylosis.

Unilateral mandibular hypoplasia in adult patients: distraction osteogenesis and conventional osteotomies in a standardized sequence

INTRODUCTION

This study analyzed the outcomes of nongrowing patients with unilateral mandibular hypoplasia treated according to a specific protocol, which combines distraction osteogenesis, orthodontic treatment, and conventional osteotomies.

MATERIALS AND METHODS

The patients treated were objectively evaluated. Patient's satisfaction was assessed by questionnaire. Surgical changes were analyzed using cephalometry and three-dimensional facial surface data before surgery (T0) and at long-term (T1) follow-up.

RESULTS

Four patients were included in this study. The normalization of facial proportion and a high increase in symmetry were evident. Residual defects were documented in the postoperative symmetry of the chin. In the questionnaire, all patients gave favorable responses to their facial changes; for most of the objective parameters, all patients improved.

CONCLUSIONS

A multistage treatment protocol for the correction of facial deformities in patients with unilateral mandibular hypoplasia is a valid procedure for skeletal and occlusal stability. An evident improvement of the facial appearance is also achieved.

Temporomandibular joint replacement: a New Zealand perspective

Alloplastic total temporomandibular joint replacement (TMJ TJR) has been performed in New Zealand utilizing the TMJ Concepts patient-fitted system since 2000. The data analysed in this study were collected retrospectively from questionnaires sent to all maxillofacial surgeons in New Zealand who had implanted TMJ Concepts devices between 2000 and 2011. A total of 63 devices were implanted in 42 patients (13 males, 29 females) during this 12-year period. The primary indication for TMJ TJR was end-stage joint disease resulting from ankylosis and arthritis. The mean age of the patients was 47 years (range 7-80 years). The most common complication reported was transient facial nerve impairment in 4.8% of the patients. Objective results, measured as the maximal incisional opening, improved by a mean of 17.3mm (P<0.01); 90% of patients reported improved quality of life. New Zealand oral and maxillofacial surgeons have concluded that TMJ TJR using the TMJ Concepts prosthesis is a reliable treatment option for the management of end-stage TMJ disease.

Late reconstruction of condylar neck and head fractures

Condyle fractures are a common injury, but only a few of these injuries require immediate or late reconstruction. The complications that most frequently necessitate condylar reconstruction include proximal segment degeneration, malunion, and ankylosis. Costochondral grafts and total joint prostheses, both stock and custom, remain the most common methods of reconstruction. Reconstruction plates with condylar extensions should only be used temporarily as an unacceptable number cause serious complications. Distraction osteogenesis may have an occasional role in reconstructing the posttraumatic condyle.

Alloplastic or autogenous reconstruction of the TMJ

Reconstruction of the irreparably damaged temporomandibular joint (TMJ) is dependent on the cause of damage and the patient's age. In childhood the current preference is for autogenous reconstruction which can potentially "grow" with the child. This is either with soft tissue interposition (temporalis fascial interposition), local osteotomy, distraction osteogenesis, non-vascularised tissue (costochondral, sternoclavicular) or vascularised tissue (second metatarsal). Current debate centres around the possibility of alloplastic reconstruction particularly where autogenous tissue has failed. The resultant failure of growth - if this occurs, can be dealt with in late adolescence with either osteotomy, distraction osteogenesis or replacement of the condylar component of the prosthesis. In the adult the choice is currently in favour of alloplastic reconstruction as this gives a more stable long term result and facilitates early mobilisation. Initial cost is clearly an issue, but when weighted against the reduced length of stay and reduced morbidity, often the costs are equivalent in the short term and come to benefit alloplasts in the medium term. Their long term outcomes beyond 15 years are however not clear.

Evaluation of temporomandibular joint total replacement with alloplastic prosthesis: observational study of 27 patients

Background Temporomandibular joint (TMJ) total replacement with alloplastic prostheses has been performed since 1960s. Research in these last two decades has achieved important improvement in the development of biomaterials, design, adaptation, and fixation of the prosthesis components. Objective To evaluate total TMJ replacement with alloplastic prostheses. Methods We studied 27 patients, between 19 and 73 years old, who had total TMJ uni- or bilateral replacement surgery with custom-made alloplastic prostheses manufactured by TMJ Concepts, Inc. (Ventura, CA) between 1996 and 2011. The general data and preoperative measurements were taken from medical records. Subjective data related to pain, diet consistency, and current quality of life were collected with a questionnaire answered by the patients; measures of maximum interincisal opening and lateral mandibular movements were obtained from direct examination. Results We found significant difference (p < 0.05) comparing pre- to postoperative results about improvement in mouth opening, pain relief, and satisfaction with the surgery and diet consistency. Conclusion The results of this study show that total alloplastic TMJ prostheses are an efficient, safe, and stable long-term solution for patients who need TMJ total replacement.

Two-stage total prosthetic reconstruction of temporomandibular joint in severe and recurrent ankylosis

Temporomandibular joint ankylosis is a devastating condition for the patient associated with both functional disability and aesthetic deformities. Various techniques have been described in the literature to overcome this problem; however, there is still a high risk of reankylosis in patients undergoing multiple temporomandibular joint operations, severe heterotopic ossification, and fibrosis of the soft tissues. This study includes 5 patients with severe and recurrent ankylosis. Two-stage reconstruction with excision of the bony mass and placement of a distraction device in the first stage, followed by gradual distraction of soft tissues, and placement of a total joint prosthesis in the second stage were performed in all patients. The 2-step approach helps to overcome the fibrosis and adhesions in the soft tissues and allows placing an implant with a higher ramus component. This approach seems to be a useful and effective technique for the management of such patients with high risk of reankylosis.